Healthcare Provider Details

I. General information

NPI: 1255615522
Provider Name (Legal Business Name): ABBASSI JOHNSON PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 10/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 W BADILLO ST
COVINA CA
91722
US

IV. Provider business mailing address

558 W BADILLO ST
COVINA CA
91722-3762
US

V. Phone/Fax

Practice location:
  • Phone: 626-331-0506
  • Fax: 626-858-1788
Mailing address:
  • Phone: 626-331-0506
  • Fax: 626-858-1788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number54047
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number55948
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number54322
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number47476
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number24358
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberOMS36
License Number StateCA

VIII. Authorized Official

Name: ARTHUR JOHNSON III
Title or Position: OWNER
Credential: MD, DDS
Phone: 626-331-0506